Chapter 45, Sections 23 and 24, Participant Costs, Funds,

Wyoming Department of HealthDivision of Healthcare Financing

DD Waiver Provider Training Series

Provider Training SeriesChapter 45, Sections 23 and 24, Participant Costs, Funds,

and Personal Property(Module #11)

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Welcome to the Division of Healthcare Financing (Division), Home and Community Based Services (HCBS) Section’s Provider Training Series for Chapter 45 of the Department of Health’s Medicaid Rules (Rules). These rules govern the home and community based Comprehensive and Supports Waivers, hereinafter referred to as the DD Waivers.

Chapter 45, Section 15(d) requires waiver providers to complete training in specific areas prior to delivering services. Individuals who complete all of the Series training modules and associated training summaries will be in compliance with this specific requirement. Please note that providers are responsible for ensuring they meet all training requirements, which are established throughout Chapter 45, prior to delivering waiver services.

This module covers Sections 23 and 24, which address the notice of costs to the participant, as well as participant funds and personal property.

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To clearly establish the provider’s obligation to notify participants of the costs they will incur during the provision of services, and outline the provider’s responsibility to respect and protect a participant’s money and personal property.

Purpose of This Training

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The purpose of this training is to clearly establish the provider’s obligation to notify participants of the costs they will incur during the provision of services, and outline the provider’s responsibility to respect and protect a participant’s money and personal property.

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Training Agenda

► Reason for, and requirements of, the notice of costs► Policies and procedures that are required to protect a

participant’s funds► Prohibited practices related to a participant’s funds► Policies and prohibited practices that apply to a

participant’s personal property

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By the end of this module, the following topics will have been introduced and explained. ● The importance of notifying participants of the costs they will be responsible to pay,

and the specific requirements of the notification.● The policies and procedures that providers are required to develop and implement in

order to ensure that a participant’s money is protected.● Specific practices related to the expenditure of participant funds that are prohibited.● And finally, how the policies and prohibited practices are applied to a participant’s

personal property.

Please note that, for the purpose of these trainings, providers include provider staff and case managers, unless there is a specific need to make a distinction.

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ChoiceFreedom to make choices is a human right. Participants need to know up front if they will be required to pay additional fees while receiving services, and how their property will be protected and respected.

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A theme throughout all of the Division’s provider training modules is the fact that home and community-based waiver services are based on the tenet that people have the freedom to make choices that impact their lives. It should go without saying that, even if a participant has a legally authorized representative or representative payee, participants should have choice in how they spend their money. As established in Section 4, this is one of the basic rights that participants have. Participants need to know up front if they will be required to pay additional fees while receiving services from a provider, and how their property will be protected and respected. When they have this information, they are able to make an informed choice on if the charges are something they are willing to pay so they can make the ultimate decision on if the provider meets their needs.

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Providers must notify participants of costs and terms of payment.

Notice of Costs

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Chapter 45, Section 23 establishes that providers must develop and implement a system to notify participants and legally authorized representatives of costs they will have to pay for services and items, and the terms of payment. The notice must be given in writing.

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► Before services begin► Before changes► With adequate time to

review notice

When is Notice Required?6

Providers must give a written notice of costs before a participant starts receiving services. Any time there is a change in those costs, participants must receive notification of those changes before they occur, and with enough time for them to review the notice and determine if they wish to continue to receive services from the provider, or look elsewhere for services.

Section 23 does not give a specified time by which notification must be given, but best practice would suggest that the provider should give written notice at least 60 to 90 days before a change to costs is implemented in order to give the participant and legally authorized representative time to review the notice, and choose to transition to another provider if necessary.

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Notice Requirements

► Participant will not be charged for services oritems covered through other funding sources.

► Who is responsible when a participant's personalitems are damaged or missing.

► How the participant will be compensated whenothers use the environment and eat food paid forby the participant.

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Section 23 establishes specific requirements that providers must include in their notice of participant costs.

● A provider’s notice must specify that the participant will not be charged for services oritems that are covered through other funding sources. This includes, but is not limitedto items that are necessary to provide habilitation services and transportation that isincluded as part of the cost of services. Please refer to the Comprehensive andSupports Waiver Service Index (Service Index) for more information on service ratesthat include transportation costs.

● A provider must specify who is responsible if a participant’s personal property isdamaged or goes missing while they are receiving services. For clarity, the provider maywant to distinguish between scenarios such as the participant damaging their ownproperty, other participant’s damaging or stealing the property, and property that isdamaged or goes missing as a result of a provider or provider staff member neglectingto provide adequate supervision, or property damage that is a consequence of theprovider or provider staff member escalating a participant’s behavior.

● If a participant lives in a shared or group setting that is owned or operated by theprovider, the provider must explain if and how the participant will be reimbursed orcompensated when visitors in that shared setting use products or eat food that hasbeen purchased by the participant.

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► Room and board► Extraordinary transportation► Support with technology► Moving expenses► Staff expenses for activities

requiring supervision

Notice Examples8

Every provider is required to identify the costs that will be passed on to participants. Some examples of these costs may include:

● Room and board - If there is a set rent amount or formula that is used to determine rentfor a provider owned setting, this may be included in the notice of costs. The cost ofrent must be included in the participant’s lease agreement, which is required in rule. Ifthe provider charges a board fee, the amount of the fee, as well as what the fee covers(food, supplies, phone and cable) should be included in the notice.

● Reasonable transportation expenses are included in most service reimbursement rates.However, if a provider is asked to drive a participant to the airport, and that airport is150 miles away, the provider may choose to charge the participant for the additionalwear and tear and fuel that is associated with the trip. The participant must be notifiedof this potential cost. Please note that transportation for out-of-town medicalappointments cannot be billed to the participant.

● If a participant chooses to move, the provider may charge the participant if the provideris responsible for the labor involved in moving the participant’s belongings. Thispotential cost should be disclosed. Please keep in mind that if a participant moves atthe request of the provider, the provider cannot charge the participant for movingexpenses.

● Participants regularly attend events and activities in their communities. Occasionally aparticipant can navigate their community independently, but often times a participantneeds support. If a participant needs support when they go to a movie, work out at the

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● gym, or attend a sporting event, the provider or provider staff member who supportsthem will need to gain entrance to the activity. If this cost is passed on to theparticipant, the participant must be notified in advance. The provider will need to bevery clear as to what the participant will be expected to pay in these situations.

○ It is important to note that many local businesses will grant free access tosupport staff. Providers should work with local businesses to determine if this isan option. It is also important to note that, while participants may need to payan entry fee, they should never be required to pay for food. The participantmay need to buy the movie ticket for the provider or staff member, but theyshould never pay for snacks. If a participant needs support at a restaurant, theprovider or staff member should offer that support while drinking a glass ofwater, unless the provider or staff member purchases their own meal.

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Participant Funds Providers that serve as a representative payee, manage a participant’s money, receive benefits or money on behalf of a participant, or temporarily safeguard a participant’s money must comply with Section 24.

Section 24 establishes rules for providers that take responsibility for a participant’s funds or personal property. This includes providers that serve as a participant’s representative payee, manage a participant’s money, receive benefits or money on behalf of a participant, or temporarily safeguard a participant’s money or personal property.

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If a provider maintains a cash or checking account, and has been given authorization from the participant, legally authorized representative, or representative payee to pay the participant’s bills and support the participant in discretionary spending decisions, then the provider manages the participant’s money.

What Does Managing a Participant’s Money Mean?

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To clarify, a provider can manage a participant’s money even though the provider does not serve as the participant’s representative payee and has no legal authority or obligation to do so. If a provider maintains a cash or checking account, and has been given authorization from the participant, legally authorized representative, or representative payee to pay the participant’s bills and support the participant in discretionary spending decisions, then the provider manages the participant’s money.

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► How informed consent for expenditures will be given;► How records may be accessed;► How the funds of different participants will be segregated;► Safeguards to assure that funds are used as intended;► How interest will be credited to accounts;► Charges for managing funds; and► How missing funds will be replaced.

Required Policies and Safeguards11

If a provider takes responsibility for a participant’s funds, the provider must develop and implement written policies and procedures to safeguard these funds. The provider must share these policies and procedures with the participant and legally authorized representative before agreeing to manage a participant’s funds.

Policies and procedures must include:● Information on how the participant or legally authorized representative will give

informed consent on the expenditure of funds.● An explanation of how the participant or legally authorized representative can access

their records, including their account balances, list of expenditures and deposits, earnedinterest, and any reporting that has been generated or submitted to outside entities.

● An explanation of how the participant’s funds will be separated from the funds of otherparticipants, for the purposes of reporting to the participant, legally authorizedrepresentative, and regulatory agencies such as the Social Security Administration orthe Division. Best practice suggests that if a provider maintains any kind of financialaccount for more than one participant, that each participant have separate rather thancommingled accounts.

● Information on the safeguards that the provider will implement to ensure that thefunds are used for designated and appropriate purposes. This may be accomplished byensuring that the documentation of each expenditure includes an accounting of whatwas purchased, and who requested that the purchase be made.

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● Information on how interest will be credited to accounts. If participants have separateaccounts, this explanation will be much simpler than explaining how interest is dividedamong commingled accounts.

● If the provider will be charging a fee for managing funds, including the allowable fee forserving as a representative payee, how these fees are calculated and charged. Pleaseremember that this information should also be included in the Notice of Cost.

● If, under provider management, funds go missing or expenditures cannot be justified,an explanation of how the provider will compensate the participant.

Please be aware that providers who serve as representative payees must meet the requirements established by the Social Security Administration (SSA). Chapter 45 of the Department of Health’s Medicaid Rules do not replace SSA requirements.

► Using funds as a reward orpunishment;

► Using funds as payment for damages;► Using funds to purchase provider

inventory or services;► Using funds as a loan; and► Commingling funds with provider

accounts

Prohibited Practices12

Section 24 lists some clear-cut prohibited practices related to participant funds.● Participant funds cannot be used as a punishment or reward.● Participant funds cannot be used to pay for damages, unless there is notification in a

lease or other written agreement, there is evidence that shows that the participant wasdirectly responsible for the damages, the rationale is documented, and the participantor legally authorized representative gives written informed consent to make restitutionfor the damages.

○ One crucial exception is that participants cannot be charged for damages, evenif they are directly responsible, if the damages are a result of lack ofappropriate supervision. For example, John is a participant who lives in a grouphome. His IPC states that, when he is escalated, he needs one on one supportand interaction until he de-escalates. John recently got in an argument with hisroommate, and is showing signs of escalated behavior. A provider staff membertakes John into their office so he can de-escalate. The staff member leaves theoffice to take a phone call, even though John is still visibly agitated. Johnthrows a laptop across the room, breaking it. John’s IPC clearly stated that heneeded one on one support during times of agitation. Since the staff memberdid not provide this support, John cannot be charged for the damage to thelaptop.

● Participant funds cannot be used to purchase supplies, inventory, or other services forthe provider.

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○ Providers are not allowed to charge a participant for waiver services that theparticipant has refused. Participants have the right to refuse services. Forexample, John refuses his Community Support Services, and chooses to stayhome instead. Let’s face it...we all need the occasional day off. John’s providercannot bill him for the service that he refused.

● Participant funds shall not be loaned to providers or provider staff members for anyreason. The Division has been made aware of several instances of providers or staffmembers asking a participant to pay for a tank of gas or loan them money for a meal.This practice is absolutely prohibited. This behavior is considered exploitation, and willnot be tolerated. Providers that employ staff members must ensure that all staffmembers are aware that this is absolutely inappropriate.

● Providers must ensure that participant funds are kept separate from provider moniesand accounts.

● Finally, providers that are representative payees must follow the rules established bythe Social Security Administration for representative payees. Non-representative payeeproviders must ensure that participant funds are kept separate.

Section 24 relates to a participant’s personal property as well as the participant’s money.

Participant Property

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Although Section 24 focuses on a participant’s funds, this section applies to a participant’s personal property as well.

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► Policy Requirements► How missing property will be replaced.

► Prohibited Practices► Use property as a reward or punishment;► Use property as payment for damages; and► Use property as a loan.

Policy Requirements and Prohibited Practices Apply to Property Too!

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Many of the policies that providers are required to develop and implement are specific to participant funds. However, there are policy requirements that relate to a participant’s personal property as well.

● Providers must have and implement a policy that explains how a participant will bereimbursed or how a participant’s property will be replaced if the property goes missingin a provider owned or operated setting, or while the provider is delivering services.This is a good time to remind providers that participants have a right to sleeping andliving quarters that have doors that can be locked to keep their property secure.

Prohibited practices apply to a participant’s personal property as well.● Participant property cannot be used as a punishment or reward. If a participant’s right

to access their property is restricted, the restriction must meet the criteria establishedin Chapter 45, Section 4.

● A participant’s property cannot be used as payment for damages. For example, if Johnbreaks his roommate’s Xbox, the provider cannot require John to give his Xbox to hisroommate as payment.

● Finally, just as participant funds must not be loaned to providers or provider staffmembers for any reason, a participant’s property must not be loaned out either.Providers and provider staff member should never ask or accept the loan of a phone,video game, article of clothing, or any other property that belongs to a participant.Likewise, providers and provider staff members should never ask a participant for

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● temporary lodging in their home. These actions are also considered exploitation.

1. Providers are required to give theparticipant advance notice of any feesthe participant will be charged.

2. Providers must develop and implementpolicies related to participant funds andproperty.

3. Providers who manage participantfunds must comply with MedicaidRules and, if applicable, rulesestablished by the SSA.

4. Misuse of participant funds andproperty may be consideredexploitation, and will not be tolerated.

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As we end this training, we’d like to review some of the key takeaways:

1. Providers are required to give the participant advance notice of any fees the participantwill be charged. This notice must be given in writing before the participant startsreceiving services, and any time there is a change in those costs.

2. Providers must develop and implement policies related to participant funds andproperty. It isn’t enough just to have a policy. It must be followed. The provider mustshare these policies and procedures with the participant and legally authorizedrepresentative before agreeing to manage a participant’s funds. Policies and proceduresapply to property as well. Providers must have and implement a policy that explainshow a participant will be reimbursed or how a participant’s property will be replaced ifthe property goes missing in a provider owned or operated setting, or while theprovider is delivering services.

3. Providers who manage participant funds must comply with the rules established inChapter 45. Please remember that providers who serve as a representative payee mustmeet the requirement established by the SSA. Rules established in Chapter 45 do notreplace SSA requirements.

4. Misuse of participant funds and property may be considered exploitation and will notbe tolerated.

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Questions???Contact your Provider or

Benefits and Eligibility Specialist

https://health.wyo.gov/healthcarefin/hcbs/contacts-and-important-links/

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Thank you for participating in the training on participant costs, funds, and personal property. If you have questions related to the information in this training, please contact your Division representative. Contact information can be found by clicking on the link provided in the slide.

Don’t read this section as part of the live presentationPlease be sure to complete a summary of this training so that you can demonstrate that you received training on the rights of participants receiving services.

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